Wednesday, November 15, 2006

Some Edges In The Healthcare Debate

A post on healthcare over at Tigerhawk discusses universal health care as it might develop in America. He links to folks who claim "it'll never happen," and to others who point out what the American people would absolutely require of any future healthcare arrangement, and how difficult some of those are politically. Several new aspects I had not considered at the link.

The ugly truth is that there are only three ways to allocate healthcare: auction (ability to pay), queuing (standing in line), and bureaucratic fiat (an "expert" deciding who gets what healthcare). All healthcare systems use some mixture of these three methods, with the proportions varying according to political demand, the history of local institutions, and national income. There is no a priori virtue to any one of these three allocation methods, and there is widespread consensus about the best method for many procedures. Almost everybody agrees that we should allocate breast augmentation surgery by auction, emergency care by queuing, and flu vaccination in times of shortage by bureaucratic fiat. The arguments about allocating the treatment of chronic conditions that diminish the quality of life without immediately threatening it are far more difficult. Which should come first, advanced drugs for my wife's MS, or surgery for your brother's debilitating chronic back pain? Now there's a toughie.

18 comments:

Two things I will nitpick at:1. The Tigerhawk post discusses nationalized health care, not universal health care. Mass is trying to transition to universal health care right now...all those with out private insurance are required to get state insurance. This means everyone will be covered, and the theory is that it will reduce cost in the long run, as those without health insurance notoriously neglect preventative care (cheap) and only go to the ER when they get hit with a crisis (expensive, and almost never paid). This is fairly feasible on a large scale, and would not require eliminating private companies. Nationalizing health care however, involves a universal payer. Universal healthcare I believe is a worthwhile goal, and as it can be implemented fairly gradually and with competition still around to keep them honest, it seems fairly promising. I think universal healthcare would be disasterous at the moment.

My other critique is the rather biased referal to the "bureaucratic fiat". Um, that's what the healthcare field normally calls "triaging". In the ER I work in, possibly 25% of patients actually "stand in line" and the rest are order by conditions (an "expert" deciding when you get your healthcare). To say that emergency care is decided by standing in line is to trivialize the fact that every time you use almost every aspect of the health care system, someone evaluates you and sticks you in your proper (and sometimes arbitrary) place. Yearly physicals are really the only thing that's done by queuing. References to experts evalution as a bad thing are frustrating to me because it makes it seem like that's not what you're already dealing with. You know that stab wound to the chest is going ahead of your sliced finger no matter who got there first. Anyway, I understand that the universal payer system is large, bulky and impersonal in it's triaging, but nevertheless, it's the most common method used in most healthcare settings to determine who gets appointments when.

It is certainly true that preventative care is cheap and ES care expensive, and anything we can do to move folks from one to the other saves $. I do worry that there is overoptimism how much preventative care will be used, even when it's free. People who can organize their lives well enough to go do something smart for themselves are usually organized enough to get either the wages or benefits that would pay for it. Impulsivity as a lifestyle is one of the drivers of poverty. Visiting the poor, most people are appalled by the number of fairly expensive impulse-driven purchases they have.

Still, seeing that the cost difference may be a factor of 10, we wouldn't have to help many to break even. Plus it's nicer to have people healthier.

1. The underlying tone that somehow poor people are irresponsible and refuse to get preventative care.

As a stay at home mom, who has made many sacrifices in order to be home, I can tell you that we pay $700 a month in order to have medical benefits for our family. What is sad about that is the fact that it costs that much for the lowest level of coverage offered through my husband's company. That also does not include co-pays, deductibles, and other expenses that can occur when a medical emergency arises.

People who cannot afford insurance are frequently charged almost double what insurance companies actually pay doctors/hospitals for their services. So, not only are they hit with an unexpected expense, but it comes at a higher price. More people could afford their medical bills if this overcharging did not exist.

We are a wealthy country. While that does not mean that we should just pour out every dollar we have into social programs, there is no reason why any mother should go without prenatal care, any child without immunizations, or any adult without basic health screenings. While I understand the complexity of complete medical care in expensive situations such as cancer, neurological issues and chronic illnesses; I see no reason why basic preventative health care cannot be offered.

2. Impulsivity...yes, a big problem for all classes of people in the US of A; but, a huge oversimplification and not reflective of all poor people or those of us who would be financially considered "lower middle class."

jonathan..Almost every disease has a much higher cure rate and is less expensive to cure when is caught early. What do you do when the cancer is at stage 4 or 3? I'm not sure. What if it's caught at 1 and has a good prognosis? That would be better.

Think about it this way, people don't just wake up one day with diabetes, heart disease, or cancer. If high blood pressure, sugar levels and other indicators were checked at least once a year it would show trends in the health of the individual. People wouldn't find out they had a condition when it's too late to prevent its progression. They would be able to get a warning and take precautions.

I don't say that I have all the answers regarding this, but, we can never experience success if we don't risk failure.

terri, my comments come from working with the mentally ill for 30 years. There is no reason to think that because a person is poor they are irresponsible. However, irresponsibility causes poverty, and many of the poor are irresponsible.

The chronically mentally ill draw a pass on this from me. Most do what they can, as best they can, in a much harder situation than any of us would care to face. But I don't want to have excessive optimism about what we could do about health results by making certain types of preventative care more available. Some would make use of the availability, and the society would have lower social and economic cost. But many aavailable services go unused because people will not even take the time to sign up in advance, make appointments in advance, or fill out the necessary forms. Then they seek emergency services.

One should add in costs. Canada pays a lot less to get health care covereage that is better in some ways, no different in others and worse in a few (about 2.4 times less, depending on how you measure it).

My brother in Ohio just had surgery for angina. He got care identical to the Canadian system, ie same day stent. My other brother just had a torn retina fixed in Alberta: He would have been a touch better off in the US, ie same day vs next day. My chronic pain and tremor? I'm far far better off here, many many Dr visits and no co-pay. My mother needs a knee replacement, she'd be far far better off in the States, 18 months vs 2 weeks.

So? We pay a LOT less, for service that is a bit different, but no better or worse, depending on what's wrong with you.

jw - Serious questions: Are there liability limits in Canada? In other words, does a doctor working for the national health system have to pay premiums for liability insurance? Is the government responsible?

Is it legal to advertise prescription drugs on TV in Canada?

Not-so-serious jab: I won't mention the fact that the latest prescription drugs are available at government-forced lower prices than here in the States. You can thank us for the cost of R&D later...

What happens when companies lose motivation to provide benefits to their employees, since "the government will take care of the employees"? Will there still be "private healthcare"? Any kind of governmentally-sponsored healthcare is reimbursed at a lower rate than private healthcare - even negotiated insurance rates - thus the reason most doctors only accept a certain number of Medicare/Medicaid patients. What happens as more-and-more folks are dumped into the government's system? Will it be easier or harder to even FIND doctors, when all the doctors are leaving the state (or country) to go somewhere that they can make enough money to pay off their student loans?

Tigerhawk answered your critique about "bureaucratic fiat" in the comments - one commenter brought up a similar critique. Bureaucratic fiat, in my understanding, is related to things like lack of flu vaccines - this is who we give it to first. Failure to obey those rules can result in criminal penalties.

Triage, in my opinion, is more like "first come, first served". Now, I know you will probably argue with that, but hear me out:My experience is as an EMT. (I was planning on working my way through grad school as an EMT, but I took a job and gave up on grad school.) There are different rules about how to triage accident scenes, but it boils down to this: People will be left to die, because of the severity of their injuries, when other people have been injured. A person in a single occupancy roll-over, in full arrest, would be treated with all expediency and taken to the hospital. In a major accident scene, the same person, with the same injury, would be black-tagged. It is still first come, first served, but in a "weird twist of the universe" type of way.

Failure to do triage right can end in civil penalties.

Yes, it requires expert knowledge in both cases. But in the case of bureaucratic fiat, it isn't necessarily the medical experts. (jw, do you think it is the doctors making the decision to postpone your mother's knee replacement?) It is the bean-counters.

Bubba B...the problem is that private companies are already considering not providing benefits and/or cutting the ones they do provide.

A solution has to be found. There is only so much that the average family can afford to pay for benefits. If we don't deal with this issue and TRY to find something that works, the system will continue to worsen.

If you are really poor in this country you can find help of some sort. If you're really wealthy than you will never need to worry about the costs of medical care. If you are of average income, which I think is about $39-$40,000 annualy,(I could look up this info and provide a link...but I am too lazy!:-) ) you are really under the gun. All it takes is one car accident or one diagnosis of a chronic illness for someone in your family and you're on the brink of financial disaster.

So many families are unisured or underinsured because they have to choose whether to pay the rent/mortgage payment, or pay for benefits that they may or may not need.

More than once when things have been tight I have contemplated dropping the insurance on the odds that we would have an uneventful year medically. We have never done this, but the thought has crossed our minds. I am too practical to take that risk, but others in more extreme circumstances are not.

First...utterly valid criticism. I'm of the "lets try it and see" camp. Healthcare coverage right now (as Terri has been mentioning)isn't doing so hot for one class of people, and something needs to change. America spends more per person on healthcare than any other country, and does not have the best results. Thus, I'm in to trying other options. You may prove correct in your criticisms, but I think it's valid to try. That's part of my larger view on laws...I don't see them as saviors and am a big advocate for a lack of emotional attachment to them. Sometimes you try stuff and it just doesn't work. I'm okay with that. I think there's enough good in the idea to warrant trying. To note: Mass already is in a primary care doctor shortage, brought on more by high housing prices than anything.

I'm still not sure I'm buying your waiting in line argument, but I would make the compromise that he didn't make a good category for triage. After 3 years in the ER, EMT and HAZMAT certification, and more disaster and MCI drills than I care to think about, I'm familiar with how triage works there. I can see why you're putting it where you're putting it, but I felt the "waiting in line" label was a gross oversimplification, designed to cast other systems in a light that made them look more complicated.

I'll give you your bean counters point though. I'm actually considering going in to healtcare admin. just because I think they suck so much.

A significant portion of private companies have begun offering health benefits. They didn't before, but now they do. Why? Low unemployment is one reason. And a private company "considering" dropping health care, or lowering the net benefit, is not the same as the company actually DOING that. Companies have entire departments devoted to playing with numbers. (The company which merged with my current company made a splash back in the 90's when an internal report was made public. The report was an analysis of how much money the company could make if it fired all of the engineers and just continued selling the same products. Of course, the company wasn't considering it - it was informative from various perspectives to see what would happen, and how the market would most likely respond to a stagnant product line.)

Why do you say "we don't have the best results"? Would health care coordinated by a government bureaucracy be any better?

I am a strong proponent of free market principles. Unfortunately, one of the reasons that insurance is not affordable is because of the government constantly butting in, telling the insurance companies what extra things they have to pay for. Let the free market work - more government won't help.

I think that the government should step back from insurance companies, stop telling them what they have to pay for, and give massive tax credits for insurance payments/health expenditures.

I like your comment: "...am a big advocate for a lack of emotional attachment to them..." I agree with that whole-heartedly. Unfortunately, politicians don't seem to agree with that.

I didn't know you worked in the medical field - many people don't understand what triage is, so that is why I explained it how I did.

Again, referring to my comment to terri, I am unabashedly free market. When something appears broke, the first thing I do is look for a governmental reason. The government piles restrictions and requirements, also yearly, onto the insurance companies. The government, to some extent, is also responsible for excessive awards in lawsuits (seeing as how, at a minimum, the judiciary is PART of the government.)

Free markets alway works. Yes, the government must put in place the necessary checks to protect the weak and helpless (no, you shouldn't be allowed to put arsenic in your cosmetics so it will make people's cheeks rosy!!)

But we need to realize something about the healthcare debate: Why is good healthcare considered a "right"? Why is healthcare considered a right at all? A famous supermodel (Beverly Johnson, I think) was once quoted as saying that everybody should be allowed to have plastic surgery. She considered plastic surgery as a right. Obviously, that is asinine, but where do we draw the line?

The treatments which so many consider a right nowadays would have been miracles even twenty years ago. My sister-in-law had Hodgkin's disease ten years ago. Thirty years ago, her condition and how far along it was would have been a death sentence. She is completely healthy, now.

The basics of treatment twenty years ago are not what drives health care costs. It is the latest and greatest, coupled with extraordinarily high liability insurance fees, which drive most of the growths in health care costs. Twenty years ago, we didn't have Zicam, or flu vaccines, or AIDS drugs, or HPV vaccines, or...

(Speaking of liability costs, I read a set of stories a few years ago, about doctors that had to stop working for free at clinics to help the poor. They were getting SUED by those folks they were trying to help. Their liability insurance companies told them to stop. They had no choice.)

My point is, the more government is involved, the less we get out of our healthcare industry. The same is true of any industry. But when the government is paying for things, do you think that there will be enough money to pay for research? We are a generation away from major breakthroughs, including spinal regeneration, chronic disease eradication (like MS), shoot, maybe the cure for the common cold. Do you think that kind of research will continue at its current pace if the government (which is notoriously short-sighted) starts paying for everything?

Now, there are a few ideas to make things more affordable: - Get the government out of the insurance companies under-drawers. (This has to be done at the federal level, where the laws are in place.) - Allow doctors to sign agreements with patients to limit the amount of liability costs. Currently, those agreements are illegal by federal law. Doctors make mistakes, everybody does. Why do we expect them to be perfect? - Make Canada (that healthcare utopia) and the rest of the world help pay for the research costs that are currently paid predominantly by US citizens. - Limit punitive damages in lawsuits. (I think this should be done at the state level.)

Maybe I am setting up a straw-man argument, but I wanted to give "the other side". Nobody has a "right" to healthcare. Period.

Bubba B...your comments about the free market are interesting, but I find them a little frightening from a christian perspective. I am by no means a communist or socialist and am all for capitalism, but the free market does not solve every problem encountered in life.

The "free market" is exactly the cause for the discrepancy between what insurance companies pay for a service and what a person without insurance actually pays. They get discounts because they bring such a large clientele to a given hospital and/or doctor. If those doctors don't give a steep enough discount to the ins. company than the ins. company removes them from their list of providers. So, the ins. company and doctors/hospitals are locked in a never ending battle of supply and demand. They use their influence to garner financial advantage and profits. That's capitalismn in its purest form. The problem? It screws everybody else in the process.

For your sake, I hope that you are never without insurance through some twist of fate. Because if you are and you have kids and one of them gets seriously ill, I'd be interested in how much faith you put into the "free market" theory of health care.

With great power comes great responsibility. Making money has its place in life and in providing for a family, but it should hardly be the guiding force in all we do and how we respond to problems in our homes, communities and nation. What's the point of making a lot of money if you don't do something useful and beneficial with it?

Glad you liked the non emotional politics statement. I really think that alone would solve most of our problems in this country...if people could just admit things weren't working as planned and move on.

To respond to my quote that you attributed to terri originally...my assertation that our system doesn't work well is strictly from a public health viewpoint. The last numbers the World Health Org. published showed the USA spending over $5000/person/year on healthcare, the next closest country spending in the $3000/person/year range, and our life expectancy was maybe 15th or so? Meaning other countries spend dramatically less with greater results. Some of those numbers are wrong, but you get the point.

Next, I'm a huge advocate for liability reform. I used to frequently explain the wait time in the ER to patients by saying two words "lawsuit prevention". Sorry, we can't "just look at" or "just give you..." x,y, or z, because we have to worry about lawsuits. Also, I did my undergrad in biomedical engineering, so I'm familiar with the R&D debates...and the thought of all that time and money being put in to a new drug, then blaming the drug companies for wanting a profit makes me cringe.

Your healthcare is not a human right argument troubles me though. Sure plastic surgery is not a human right, but where do you draw the line on the other end? Is sanitation to prevent disease a basic human right? Clean drinking water? Nutritional adequacy? All of those ultimately fall to the public health field, and where do you say that people only get them on an ability to pay basis? What's your line for human rights? On the other end, sometimes healthcare is considered a human right because of what it prevents for everyone. Controlling TB is a good idea because it prevents epidemics...even though control starts in poor communities. Sometimes prevention means you have to give expensive drugs to poor areas because an outbreak there can become unmanagable by the time it reaches people who can afford treatment. Health care can never, in my opinion, be strictly free market because what affects one group can easily get out of control for other groups. Essentially, what I'm saying is, lines will have to be drawn somewhere whether we like it or not, and strict free market will put us all in more danger in the long run. From infectious disease to psych disorders to substance abuse, these things have many consequences for those outside the one who actually has the disease.

Oh, and by the way, Canada drives me nuts. Have you ever seen the Chapelle Show? At one point, he does a fake political add where he advocates solving our healthcare prescription drug cost issues by forging fake Canadian IDs to get them back for taking all our drugs and selling them for cheaper. It was pretty brilliant. The whole "lets be smug because we provide cheap healthcare while relying on you to come up with the medical advances" thing makes me want to kick things.

I don't know who's still reading at this point, but I thought I would add that our current healthcare system - which does have gaping holes - has been called a mixture of the worst aspects of both capitalism and socialism. I'm not sure that's quite right, because I don't think it's the socialist and capitalist parts that are the downfall as much as the bureaucratic regulatory parts.

If you want to buy health insurance, you have to buy a Mercedes. Recently there was a NH case in which a student was taken off her parents' insurance because she had to drop out of school because of illness. It's a sad case, and everyone could see the point of "well, what the hell did you expect the family to do?" So the family went about getting the law changed so insurance companies can't do that. "Michelle's Law," I think it is. Now Michelle wants to devote the next few years of her life to getting similar laws passed in every state.

Well, it sounds heartless to say that's a bad idea, doesn't it? It's very kindly meant, and all that. But you add all these requirements up for health insurers, and they don't have much wiggle room. The cost goes up for everyone.

Almost every one of those regulations is a Good Idea in some way.

Some states allow you to buy high-deductible or catastrophic insurance. But mostly, if you buy insurance, it has to cover most of what happens to you. Terri's dilemna is not unusual, and it is a real hole in the system. But if terri's family could buy high-deductible, high co-pay insurance, basically paying a lot out of pocket at point of service and not so much to the HMO, leaving a fence up against catastrophe, they could knock that high premium down some.

AVI...that would be nice, but that is sort of what we already have. We are part of Blue Cross Blue Shield's risk/reward program. We had to switch to this lowest level of care this past year during open enrollment simply because the next level up, which is what we were using, increased so much in price. Our monthly premiums have increased by probably almost $300.00 over the past 4 years.

The current risk/reward program has worked well for us so far because we have not had any major illness this year. However, if something really unforeseen happened, our out of pocket limits would be about $8,000. It is reasonable on a health maintenance basis, but the "risk" part is that you're up a creek if something catastrophic happens.

What's funny is that our local paper just did an article regarding this very thing today. I would reference it, but it wasn't an AP story and I would have to quote the actual paper, which would list the city we're from.

The point of it is that the cost of company-sponsored health care for 2007 jumped at twice the rate of inflation for the third year in a row. It also states that most companies have already done what they can to deter cost by switching companies, passing on the cost to employess, choosing different plans, etc.

At some point people will have to begin dropping coverage that they can't afford which will only lead to more upaid hospital bills and conditions being caught later.

If I didn't have faith that the Great Physician was watching over us it would be depressing! But, life is still good.